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Endoscopic Urethrotomy: Does it Live Up to its Promises?
VoL 127. March Printed U.S.A.
TEE JGiJ5.J.·iAL OF UROLOGY
Copyright© l982 by The VVilliar:o.s & VVilkins Co.
ENDOSCOPIC URETHRO'l~OrviY: L. BOCCON GIBOD
AND
B. LE PORTZ
From the Clinique Urologique Hopital Cochin, Paris, France
ABSTRACT
Endoscopic cold knife ureth:rntomy was done on 160 patients with urethral strictures. Of these patients 120 have been followed for 6 months to 2 years. The initially good results (56 per cent cured at 6 months) do not stand the test of time since only 25 per cent of the patients can be considered cured after 2 years. Despite these less than triumphant results endoscopic urethrotomy, which is performed easily and uncompromising to secondary urethroplasty, should be tried as a pnmary procedure. Since the early publications by Sachse, 1 and Matouschek and Michaelis2 the success of endoscopic cold knife urethrotomy has questioned the role of open urethroplasty. A total of 160 patients with urethral strictures who underwent endoscopic urethrotomy with a minimum followup of 6 months form the basis of this report.
TABLE
1. Etiology of stenoses No.(%)
Inflammatory Post-endoscopy Traumatic Congenital-unknown Total
47 (30) 77 (48) 21 (13)
~ 160
PATIENTS AND METHODS
There were 160 patients ranging from 14 to 80 years old (mean 45 years) with strictures located mainly in the bulbar and/or membranous urethra. One of 2 strictures was the result of an endoscopic procedure of some sort (table 1). Diagnosis of the stricture was made retrograde and voiding cystourethrography. Endoscopic urethrotomy was performed with the Sachse urethrotome 1 with the patient under general or spinal anesthesia. The stricture was catheterized with a long filiform and incised at the 12 o'clock position throughout its entire length and depth. Hemostasis was performed with a ball electrode. A 20F silicone or latex catheter was left in situ for 3 dayso Postoperatively, sulfonamides were given during 3 weeks and the patient was asked to perform hydraulic self-dilation for the same interval, that is occlusion of the terminal penile uTethra for 10 seconds before voiding through the meatus. 1 The patients were studied with urinalysis, voiding urethrography and uroflowmetry 6, 12 and 24 months postoperatively. RESULTS
TABLE 2.
Morbidity in 160 patients
Noo False passage Breaking of knife Section of catheter Transient impotence Urothelial tumor
6' 1 3
1 1
* Two patients underwent secondary urethroplasty and l underwent repeat urethrotomy.
bulbar strictures. Patients with inflammatory strictures seemed to fare less well than those with traumatic and iatrogenic strictures (fig. 6). The success rate at 6 months decreased from 64 to 48 per cent owing to the presence of infected urine, and from 61 to 52 per cent when the catheter was left in situ >3 days. On the whole, the best results were obtained on short, proximal strictures vvith no urinary infection. Of 56 patients considered failures 13 have undergone a secondary open urethroplasty with no particular difficulty and 34
There was no mortality and the morbidity was minimal (table Of the 160 patients 40 (25 per cent) were lost to subsequent followup, thus, leaving 120 evaluable patients. Results were considered good when the flow rate was 15 ml. per second, voiding urethrogram was normal and urine was and medium when the flow rate was between 10 and 15 mlo per second, the pre-stenotic urethra being dilated on the voiding cystourethrogram. Results were considered poor when reoperation was necessary or the patient resumed periodic bougienage. On the whole, the results were disappointing. Of the patients 56 per cent were considered cured at 6 months, 43 per cent at 1 year and only 25 per cent at 2 years (figs. l to 5). Factors that had no influence on the outcome were age, previous periodic dilations, radiological evidence of urethral and prostatic inflammatory changes, and the type of catheter (latex or siliconecoated). On the other hand, length, location and cause of the stricture, as well as urinary infection and duration of the indwelling catheter, seemed to influence the results. Short strictures (<5 mm.) had an 85 per cent success rate at 2 years. The more proximal the stricture the better the results: the success rate was 100 per cent for postoperative bladder neck stenosis, 45 per cent for membranous strictures and 40 per cent for Fm. 1. Urethrograms show post-transurethral resection bulbomembranous stricture.
Accepted for publication May 8, 1981. 433
434
BOCCON GIBOD AND LE PORTZ
Fm. 2. Normal urethrograms in same patient as in figure 1 show good result 3 months after endoscopic urethrotomy. Flow rate was 20 ml. per second.
have undergone repeat endoscopic urethrotomy, 27 having been followed up to 6 months with a 63 per cent success rate to date. Eleven patients have had another endoscopic procedure at the same setting: 10 underwent transurethral prostatic resections with no adverse results and 1 underwent transurethral resection of a bladder tumor followed 6 months later by the development of an infiltrative urothelial tumor at the urethrotomy site. DISCUSSION
The technique of endoscopic cold knife urethrotomy, developed by Sachse, 1• 3 and Matouschek and Michaelis2 • 4 from the endoscope of Keitzer and associates, 5 seems to give results that question the role of open urethroplasty in the management of urethral strictures. Indeed, this minor surgical procedure has much to offer: no mortality, a low rate of postoperative complications (no impotence) requiring only a short hospital stay, it can be repeated, it does not compromise a secondary urethroplasty and, finally, it allows endoscopic treatment of associated lesions of the lower tract at the same time without decreasing its efficacy.
Fm. 3. Retrograde urethrograms in same patient as in figure 1 show recurrent stricture 1 year after urethrotomy. Flow rate was 10 ml. per second.
Fm. 4. Urethrograms in same patient as in figure 1 show pre-stenotic dilatation of proximal urethra 2 years after urethrotomy. Flow rate was 10 ml. per second.
In our hands endoscopic urethrotomy did not give the 70 to 80 per cent success rate reported by some investigators 1- 4 , 6 • 7 but our results were similar to the 40 to 50 per cent cure rates 1 year postoperatively reported by others. 8- 12 These results also are curiously similar to those reported by other urologists using
Otis urethrotomy followed by 3 to 6 weeks of silicone urethral catheter drainage. 13- 15 This discrepancy cannot be attributed entirely to failure to use postoperative intraurethral antibiotics or anti-inflammatory ointments, 1 the efficacy of which has not been established,6· 11 but probably to the use of urethrograms
435
ENDOSCOPIC TJR~T}Ift070l½Y EHDOSCOPIC URETF.RO'l'OPY OVERALL PESULTS
Good_;.15 ml/sec
l 00 %
Good and medium lo ml/sec 70
50 %
M6
FIG. 5
%
~
100
TIIAUMA
., ___ _,, I AT!'IOGEftjlC
@•••~
BNflAMMATO!ll't
e•"
Yis!IUJOWI\!
0
0
so
2. Niatouschek, E. and IVEchaelis, W, A.: Internal urethral strictures in men under endoscopic control. Urol. 30: 266, 1975. 3. Sachse, H.: Sie Sichturethrotomie mit scharfem Schnitt. Indikation-Tecknik-Ergebnisse. Urologe A, 17: 177, 1978. 4. Matouschek, E.: Internal urethrotomy of urethral stricture under vision-a five-year report. Urol. Res., 6: 147, 1978. 5. Keitzer, W. A., Cervantes, L., Demaculangan, A. and Cruz, B.: Transurethral incision of bladder neck for contracture. J. Urol., 86: 242, 1961. 6. Gaches, C. G., Ashken, M. H., Dunn, M., Hammonds, J.C., Jenkins, I. L. and Smith, P. J.: The role of selective internal urethrotomy in the management of urethral stricture: a multi-centre evaluation. Brit. J. Urol., 51: 579, 1979. 7. Walther, P. C., Parsons, C. L. and Schmidt, J. D.: Direct vision urethrotomy in the management of urethral strictures. J. Urol., 123: 497, 1980. 8. Renders, G., De Nobel, J., Debruyne, F., Delaere, K. and Moonen, W.: Cold knife optical urethrotomy. Urology, 14: 475, 1979. 9. Bandhauer, K.: Harnrohrenplastik nach Urethrotomia interna. In: Aktuelle Therapie der Harnrohrenstriktur beim Mann. International Symposium, Vienna, 1979. Edited by H. Haschek. Vienna: Urologische Abteilung der Allgemeinen Poliklinik der Stadt Wein, p. 65, 1979. 10. Lipsky, H. and Hubmer, G.: Direct vision urethrotomy in the management of urethral strictures. Brit. J. Urol., 49: 725, 1977. 11. Sacknoff, E. J. and Kerr, W. S., Jr.: Direct vision cold knife urethrotomy. J. Urol., 123: 492, 1980. 12. Kinder, P. W. and Rous, S. N.: The treatment of urethral stricture disease by internal urethrotomy: a clinical review. J. Urol., 121: 45, 1979. 13. Carlton, F. E., Scardino, P. L. and Quattlebaum, R. B.: Treatment of urethral strictures with internal urethrotomy and 6 weeks of silastic catheter drainage. J. Urol., 111: 191, 1974. 14. Katz, A. S. and Waterhouse, K.: Treatment of urethral strictures in men by internal urethrotomy. A study of 61 patients. J. Urol., 105: 807, 1971. 15. Boccon Gibod, L. and Steg, A.: Le traitement chirurgical des retrecissements de l'urethre. Apropos de 162 cas. J. Chir., 116: 93, 1979. 16. Kirchheim, D., Tremann, J. A. and Ansell, J. S.: Transurethral urethrotomy under vision. J. Urol., 119: 496, 1978.
0-<------------;----------;M6
M12
M24 T
EDITORIAL COMMENT FIG. 6
as well as uroflowmetry in postoperative evaluation of the patients and to the length of our followup. Nevertheless, we believe that endoscopic cold knife urethrotomy should be considered a primary treatment for patients presenting with any type of urethral stricture. On the whole 6 of 10 patients will be cured at 6 months, 4 at l year and 2 at 2 years, for a 2-year cure rate of 20 per cent. In cases of short and/or proximal strictures the 2-year cure rate is well >80 per cent, identical to what the best open can offer. 16 Postoperative bladder neck contracture re,sp,onds dramatically to cold knife incision, 7 ' 16 If the stricture recurs repeat will give the same results and should be advocated in elderly patients, vvhereas in younger open urethroplasty can be performed vvithout any particular difficulty. REFERENCES
1. Sachse, H.: Die transurethrale scharfe Schlitzung der Harnrohren-
striktur unter Sicht. Munsch. Med. Wschr., 116: 2147, 1974.
The authors have indicated that direct vision urethrotomy is not the panacea for stricture management that we previously were led to believe. They have a sizable series of strictures incised adequately with considerable skill. The followup is sufficiently long, for the first time, to place the role of this procedure in proper perspective. Strictures still should be managed initially by the simplest method possible. Dilation is probably too traumatic so that most strictures should be handled initially by well executed direct vision urethrotomy, knowing that 2 of 10 short strictures will recur and be replaced by a stricture. Longer strictures require patch graft techniques that have predictable results than anastomotic methods. Short post-traumatic dense strictures should be repaired by overlapping spatulated primary anastornotic urethroplasty after a well mobilized urethral procedure has been performed. Short inflammatory and post-instrumentation strictures should be incised initially by direct vision techniques after carefully determining stricture length, and establishing patency and adequacy of the urethrotomy by the use of appropriate bougies and followed by careful interval monitoring of voiding flow rate. The complication rate is low but priapism and impotence have been reported in patients with longer strictures. The procedure does not preclude the subsequent use of open surgical techniques. L.M.Z.
TEE JGiJ5.J.·iAL OF UROLOGY
Copyright© l982 by The VVilliar:o.s & VVilkins Co.
ENDOSCOPIC URETHRO'l~OrviY: L. BOCCON GIBOD
AND
B. LE PORTZ
From the Clinique Urologique Hopital Cochin, Paris, France
ABSTRACT
Endoscopic cold knife ureth:rntomy was done on 160 patients with urethral strictures. Of these patients 120 have been followed for 6 months to 2 years. The initially good results (56 per cent cured at 6 months) do not stand the test of time since only 25 per cent of the patients can be considered cured after 2 years. Despite these less than triumphant results endoscopic urethrotomy, which is performed easily and uncompromising to secondary urethroplasty, should be tried as a pnmary procedure. Since the early publications by Sachse, 1 and Matouschek and Michaelis2 the success of endoscopic cold knife urethrotomy has questioned the role of open urethroplasty. A total of 160 patients with urethral strictures who underwent endoscopic urethrotomy with a minimum followup of 6 months form the basis of this report.
TABLE
1. Etiology of stenoses No.(%)
Inflammatory Post-endoscopy Traumatic Congenital-unknown Total
47 (30) 77 (48) 21 (13)
~ 160
PATIENTS AND METHODS
There were 160 patients ranging from 14 to 80 years old (mean 45 years) with strictures located mainly in the bulbar and/or membranous urethra. One of 2 strictures was the result of an endoscopic procedure of some sort (table 1). Diagnosis of the stricture was made retrograde and voiding cystourethrography. Endoscopic urethrotomy was performed with the Sachse urethrotome 1 with the patient under general or spinal anesthesia. The stricture was catheterized with a long filiform and incised at the 12 o'clock position throughout its entire length and depth. Hemostasis was performed with a ball electrode. A 20F silicone or latex catheter was left in situ for 3 dayso Postoperatively, sulfonamides were given during 3 weeks and the patient was asked to perform hydraulic self-dilation for the same interval, that is occlusion of the terminal penile uTethra for 10 seconds before voiding through the meatus. 1 The patients were studied with urinalysis, voiding urethrography and uroflowmetry 6, 12 and 24 months postoperatively. RESULTS
TABLE 2.
Morbidity in 160 patients
Noo False passage Breaking of knife Section of catheter Transient impotence Urothelial tumor
6' 1 3
1 1
* Two patients underwent secondary urethroplasty and l underwent repeat urethrotomy.
bulbar strictures. Patients with inflammatory strictures seemed to fare less well than those with traumatic and iatrogenic strictures (fig. 6). The success rate at 6 months decreased from 64 to 48 per cent owing to the presence of infected urine, and from 61 to 52 per cent when the catheter was left in situ >3 days. On the whole, the best results were obtained on short, proximal strictures vvith no urinary infection. Of 56 patients considered failures 13 have undergone a secondary open urethroplasty with no particular difficulty and 34
There was no mortality and the morbidity was minimal (table Of the 160 patients 40 (25 per cent) were lost to subsequent followup, thus, leaving 120 evaluable patients. Results were considered good when the flow rate was 15 ml. per second, voiding urethrogram was normal and urine was and medium when the flow rate was between 10 and 15 mlo per second, the pre-stenotic urethra being dilated on the voiding cystourethrogram. Results were considered poor when reoperation was necessary or the patient resumed periodic bougienage. On the whole, the results were disappointing. Of the patients 56 per cent were considered cured at 6 months, 43 per cent at 1 year and only 25 per cent at 2 years (figs. l to 5). Factors that had no influence on the outcome were age, previous periodic dilations, radiological evidence of urethral and prostatic inflammatory changes, and the type of catheter (latex or siliconecoated). On the other hand, length, location and cause of the stricture, as well as urinary infection and duration of the indwelling catheter, seemed to influence the results. Short strictures (<5 mm.) had an 85 per cent success rate at 2 years. The more proximal the stricture the better the results: the success rate was 100 per cent for postoperative bladder neck stenosis, 45 per cent for membranous strictures and 40 per cent for Fm. 1. Urethrograms show post-transurethral resection bulbomembranous stricture.
Accepted for publication May 8, 1981. 433
434
BOCCON GIBOD AND LE PORTZ
Fm. 2. Normal urethrograms in same patient as in figure 1 show good result 3 months after endoscopic urethrotomy. Flow rate was 20 ml. per second.
have undergone repeat endoscopic urethrotomy, 27 having been followed up to 6 months with a 63 per cent success rate to date. Eleven patients have had another endoscopic procedure at the same setting: 10 underwent transurethral prostatic resections with no adverse results and 1 underwent transurethral resection of a bladder tumor followed 6 months later by the development of an infiltrative urothelial tumor at the urethrotomy site. DISCUSSION
The technique of endoscopic cold knife urethrotomy, developed by Sachse, 1• 3 and Matouschek and Michaelis2 • 4 from the endoscope of Keitzer and associates, 5 seems to give results that question the role of open urethroplasty in the management of urethral strictures. Indeed, this minor surgical procedure has much to offer: no mortality, a low rate of postoperative complications (no impotence) requiring only a short hospital stay, it can be repeated, it does not compromise a secondary urethroplasty and, finally, it allows endoscopic treatment of associated lesions of the lower tract at the same time without decreasing its efficacy.
Fm. 3. Retrograde urethrograms in same patient as in figure 1 show recurrent stricture 1 year after urethrotomy. Flow rate was 10 ml. per second.
Fm. 4. Urethrograms in same patient as in figure 1 show pre-stenotic dilatation of proximal urethra 2 years after urethrotomy. Flow rate was 10 ml. per second.
In our hands endoscopic urethrotomy did not give the 70 to 80 per cent success rate reported by some investigators 1- 4 , 6 • 7 but our results were similar to the 40 to 50 per cent cure rates 1 year postoperatively reported by others. 8- 12 These results also are curiously similar to those reported by other urologists using
Otis urethrotomy followed by 3 to 6 weeks of silicone urethral catheter drainage. 13- 15 This discrepancy cannot be attributed entirely to failure to use postoperative intraurethral antibiotics or anti-inflammatory ointments, 1 the efficacy of which has not been established,6· 11 but probably to the use of urethrograms
435
ENDOSCOPIC TJR~T}Ift070l½Y EHDOSCOPIC URETF.RO'l'OPY OVERALL PESULTS
Good_;.15 ml/sec
l 00 %
Good and medium lo ml/sec 70
50 %
M6
FIG. 5
%
~
100
TIIAUMA
., ___ _,, I AT!'IOGEftjlC
@•••~
BNflAMMATO!ll't
e•"
Yis!IUJOWI\!
0
0
so
2. Niatouschek, E. and IVEchaelis, W, A.: Internal urethral strictures in men under endoscopic control. Urol. 30: 266, 1975. 3. Sachse, H.: Sie Sichturethrotomie mit scharfem Schnitt. Indikation-Tecknik-Ergebnisse. Urologe A, 17: 177, 1978. 4. Matouschek, E.: Internal urethrotomy of urethral stricture under vision-a five-year report. Urol. Res., 6: 147, 1978. 5. Keitzer, W. A., Cervantes, L., Demaculangan, A. and Cruz, B.: Transurethral incision of bladder neck for contracture. J. Urol., 86: 242, 1961. 6. Gaches, C. G., Ashken, M. H., Dunn, M., Hammonds, J.C., Jenkins, I. L. and Smith, P. J.: The role of selective internal urethrotomy in the management of urethral stricture: a multi-centre evaluation. Brit. J. Urol., 51: 579, 1979. 7. Walther, P. C., Parsons, C. L. and Schmidt, J. D.: Direct vision urethrotomy in the management of urethral strictures. J. Urol., 123: 497, 1980. 8. Renders, G., De Nobel, J., Debruyne, F., Delaere, K. and Moonen, W.: Cold knife optical urethrotomy. Urology, 14: 475, 1979. 9. Bandhauer, K.: Harnrohrenplastik nach Urethrotomia interna. In: Aktuelle Therapie der Harnrohrenstriktur beim Mann. International Symposium, Vienna, 1979. Edited by H. Haschek. Vienna: Urologische Abteilung der Allgemeinen Poliklinik der Stadt Wein, p. 65, 1979. 10. Lipsky, H. and Hubmer, G.: Direct vision urethrotomy in the management of urethral strictures. Brit. J. Urol., 49: 725, 1977. 11. Sacknoff, E. J. and Kerr, W. S., Jr.: Direct vision cold knife urethrotomy. J. Urol., 123: 492, 1980. 12. Kinder, P. W. and Rous, S. N.: The treatment of urethral stricture disease by internal urethrotomy: a clinical review. J. Urol., 121: 45, 1979. 13. Carlton, F. E., Scardino, P. L. and Quattlebaum, R. B.: Treatment of urethral strictures with internal urethrotomy and 6 weeks of silastic catheter drainage. J. Urol., 111: 191, 1974. 14. Katz, A. S. and Waterhouse, K.: Treatment of urethral strictures in men by internal urethrotomy. A study of 61 patients. J. Urol., 105: 807, 1971. 15. Boccon Gibod, L. and Steg, A.: Le traitement chirurgical des retrecissements de l'urethre. Apropos de 162 cas. J. Chir., 116: 93, 1979. 16. Kirchheim, D., Tremann, J. A. and Ansell, J. S.: Transurethral urethrotomy under vision. J. Urol., 119: 496, 1978.
0-<------------;----------;M6
M12
M24 T
EDITORIAL COMMENT FIG. 6
as well as uroflowmetry in postoperative evaluation of the patients and to the length of our followup. Nevertheless, we believe that endoscopic cold knife urethrotomy should be considered a primary treatment for patients presenting with any type of urethral stricture. On the whole 6 of 10 patients will be cured at 6 months, 4 at l year and 2 at 2 years, for a 2-year cure rate of 20 per cent. In cases of short and/or proximal strictures the 2-year cure rate is well >80 per cent, identical to what the best open can offer. 16 Postoperative bladder neck contracture re,sp,onds dramatically to cold knife incision, 7 ' 16 If the stricture recurs repeat will give the same results and should be advocated in elderly patients, vvhereas in younger open urethroplasty can be performed vvithout any particular difficulty. REFERENCES
1. Sachse, H.: Die transurethrale scharfe Schlitzung der Harnrohren-
striktur unter Sicht. Munsch. Med. Wschr., 116: 2147, 1974.
The authors have indicated that direct vision urethrotomy is not the panacea for stricture management that we previously were led to believe. They have a sizable series of strictures incised adequately with considerable skill. The followup is sufficiently long, for the first time, to place the role of this procedure in proper perspective. Strictures still should be managed initially by the simplest method possible. Dilation is probably too traumatic so that most strictures should be handled initially by well executed direct vision urethrotomy, knowing that 2 of 10 short strictures will recur and be replaced by a stricture. Longer strictures require patch graft techniques that have predictable results than anastomotic methods. Short post-traumatic dense strictures should be repaired by overlapping spatulated primary anastornotic urethroplasty after a well mobilized urethral procedure has been performed. Short inflammatory and post-instrumentation strictures should be incised initially by direct vision techniques after carefully determining stricture length, and establishing patency and adequacy of the urethrotomy by the use of appropriate bougies and followed by careful interval monitoring of voiding flow rate. The complication rate is low but priapism and impotence have been reported in patients with longer strictures. The procedure does not preclude the subsequent use of open surgical techniques. L.M.Z.